Intestinal Obstruction

intussusception, bowels, symptoms, vomiting, pain, invagination, mucus, belly, child and bowel

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Diagnosis.—When a child who has been previously in good health, or has suffered merely from looseness of the bowels, is suddenly seized with violent paroxysmal colic and repeated vomiting, followed immediately, or after a few hours, by evacuations consisting of non-faecal mucus and blood, discharged with great straining, we may conclude that he is suffering from occlusion of the bowels, clue, in all probability, to iutussusception. The discovery of an oval tumour, in the left side of the belly, will confirm us in our opinion, and if we can succeed in touching the mass, by the finger in troduced into the rectum, the sign is a conclusive one. The conjunction of all the above symptoms is of importance, and the absence of any one of them is not to be disregarded. Thus, if we are called to a child who has been taken suddenly with pain in the belly, and vomiting, and whose bow els are obstinately confined, we must not conclude too hastily that an intus susception haS occurred. The pain may be extreme and paroxysmal ; the vomiting frequent and distressino-; and the constipation may have resisted aperients and enemata, without distressing of the bowels in any form be ing present. Peritonitis, which paralyses the bowel, and induces vomiting by reflex disturbance, may produce just such symptoms. On the other . hand, a passage from the bowels may take place, although intussusception has actually occurred. The appearance of one loose stool, after the beginning of the illness, is common in intussusception, for the contents of the colon below the point of obstruction are usually expelled shortly after the occurrence of the invagination. If, however, the bowels continue loose, and fiscal matter is afterwards evacuated, whether by injection or other wise, the symptom is not in favour of intussusception ; for, even if the chan nel become pervious later, after swelling has partially subsided, it is rarely free during the first Kvo or three clays of the illness. In such a case we should hesitate to ascribe the symptoms to invagination of the bowel, less the other evidence in its favour points irresistibly to such a conclusion.

Again, severe colic in a young baby is often accompanied by alarming symptoms, in which all the signs of the most violent pain may be followed by great prostration. In the attack, the child utters piercing screams, and writhes his body exactly as he does in intussusception ; indeed, in almost all cases of invagination of the bowel, we generally find that an aperient has been ordered, under the impression that the spasms of pain are the con sequence of irritation of the bowels by undigested food, or flatulent disten tion. In every case, therefore, where intussusception is possible, we must weigh the evidence very carefully, as the recovery of the child may depend upon early and accurate diagnosis of his illness. In addition to simple colic and peritonitis, intussusception may be confounded with dysentery; with impaction of hardened fca1 masses, and with intestinal haemorrhage from other causes.

In simple colic the pain, although often excessively severe, is not paroxys mal, with complete remissions, and usually ceases with the expulsion down wards of a quantity of gas. The skin is often hot, and the belly hard and swol len. There is no vomiting or tenesmus, or discharge of bloody mucus from

the bowels. It is very important to attend to these points, for the adminis tration of castor-oil or other aperient, which quickly cures an ordinary colic, cannot but be injurious in a case of intussusception, increasing the peris taltic action of the bowels, and aggravating the invagination.

Between peritonitis and actual obstruction of the bowels, the diagnosis is often very difficult. The form of peritonitis which is most apt to simu late intussusception, is that in which inflammation occurs suddenly as a consequence of ulceration and perforation of the vermiform appendix, with extravasation into the peritoneal cavity. In these cases, symptoms similar to those of obstruction may come on quite suddenly, and be very severe. But in peritonitis, the temperature is always elevated from the first ; the abdominal parietes are distended and tense, and pressure in the right iliac fossa is painful. In intussusception there is no pyrexia at the first ; the abdominal wall is lax and undistended ; there is frequent tenesmus, and, after a few hours, blood and mucus are discharged from the bowel. This last symptom, added to the signs of intestinal occlusion, is pathogno monic. The mistake is most likely to be made when the symptoms occur in a child after the age of infancy, and hmmorrhage is not present, or is slow to appear. Still, even in these cases, the absence of fever, the lax ness of the parietes, and the tenesmus should raise strong suspicions of the real nature of the disease. In all cases of doubt, a careful examina tion of the belly, while the child is under the full influence of an thetic, will usually enable us to detect the presence of a tumour in the abdomen if invagination has occurred.

It is possible to mistake intussusception for dysentery, for the mistake has actually been made. In the latter disease, the dejections are often small, and consist of thick mucus, mixed more or less intimately with blood. They are discharged with great straining and pain. Even in severe catarrh of the lower bowel, which is often improperly called "dys entery," much mucus, and often streaks or spots of blood, can be observed. But these symptoms alone are far from being characteristic of intestinal invagination. We miss the abrupt onset, the frequent vomiting, and the lax, undistencled condition of the belly. Moreover, the whole course of the two diseases is different, and true dysentery is usually an epidemic malady.

In cases of impaction offcecal matter—an accident which constitutes a real occlusion of the bowel—the symptoms of invagination may be closely simulated. Vomiting, colicky pain, tenesmus, and constipation may all be present, and on examination of the belly, a firm tumour may be detected through the abdominal parietes. But in faecal accumulation, there is usu ally a history of hard and scanty stools for a considerable period before the attack ; the vomiting is much less severe, there is no bloody mucus evacuated from the bowels, and the tumour is more superficial, does not shift its place, and can be indented by firm pressure with the fingers. If this condition be suspected, a large purgative enema will cause the tumour and consequent symptoms to disappear.

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